Provider Demographics
NPI:1922195353
Name:CALLAHAN, GLENN WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:WILLIAM
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 MCLEAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705
Mailing Address - Country:US
Mailing Address - Phone:914-423-8808
Mailing Address - Fax:914-423-8810
Practice Address - Street 1:626 MCLEAN AVENUE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705
Practice Address - Country:US
Practice Address - Phone:914-423-8808
Practice Address - Fax:914-423-8810
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0038981213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009045723Medicaid
NYP51251OtherBLUE CROSS BLUE SHIELD
NYWS1077OtherOXFORD
NYP51251OtherBLUE CROSS BLUE SHIELD
T51253Medicare UPIN